Details:<\/p>\n
–Baseline characteristics: median\u00a067 years old, 78% men,\u00a062% prior MI, 99% prior cath, 58% multi-vessel disease, 86% prior revascularization procedure,\u00a0and almost all on statin, b-blocker, ACE\/ARB, and 77% on ASA, 40% clopidogrel, 21% both, and 11% on OAC mostly for atrial\u00a0fib (65% of whom had combo OAC and antiplatelet drug, with\u00a0n=342).<\/p>\n
–Patients who had major bleeding events on multivariate analysis, not surprisingly, were\u00a0on OAC (HR of\u00a04.69), had diabetes\u00a0(HR of\u00a02.76), were\u00a0older\u00a0(HR of\u00a01.04 per year), and had impaired renal function\u00a0(HR of\u00a00.98 for each ml\/min\/1.73 m2<\/sup>\u00a0decrease in eGFR).<\/p>\n –Risk of bleeding:\u00a0when\u00a0compared to antiplatelet monotherapy, the\u00a0risk for bleeding from OAC alone was nonsignificantly higher\u00a0(HR, 1.69)\u200b, but was\u00a0was much higher when OAC was combined with\u00a0APT\u00a0(HR, 7.30)<\/p>\n –Major bleeding sites: GI (55%), intracranial (20%). of the 51 patients with major bleeds (0.6%\/yr), 18 events were fatal (35.3%)<\/p>\n –There was no difference in the combined endpoints of cardiovascular death, MI, or nonhemorrhagic stroke in those on combo therapy vs those on OAC alone<\/strong>\u00a0(HR 1.15, with CI 0.58-2.27 and p=0.697). Their figure 3 shows that the incidence of these endpoints was pretty similar in the 2 groups over a period of 800 days.<\/p>\n A few comments:<\/p>\n –From several studies,\u00a0aspirin by itself\u00a0doesn’t work so well for atrial fibrillation.<\/p>\n –BUT, OACs seem pretty good for those with acute coronary syndromes or recent MIs. The\u00a0WARIS II study\u00a0of\u00a03620 patients\u00a0post-MI\u00a0found that after 4 years\u00a0the endpoint of death, nonfatal reinfarction or thromboembolic stroke was\u00a0lower<\/strong>\u00a0in those on warfarin than on aspirin alone\u00a0for secondary prevention after MI. \u00a0The SPORTIF III and IV trials\u00a0with patients with atrial fibrillation\u00a0randomized to warfarin (INR\u00a0target 2-3) vs ximelagatran, with low-dose\u00a0aspirin\u00a0allowed. Secondary analysis of the 14% of patients on aspirin (69% with CAD, 26% with previous stroke of TIA, 41% with LV dysfunction), found\u00a0no difference in the\u00a0combo\u00a0therapy in terms of stroke or systemic embolism. And the rate of MI in the combo group (0.6%\/yr) was not significantly different from warfarin alone (1.0%\/yr), but the combo group had more major bleeding (3.9%\/yr vs\u00a02.3%\/yr).<\/p>\n –The\u00a0European Society of Cardiology’s 2010 guidelines on atrial fibrillation\u00a0suggest OAC monotherapy in those with atrial fibrillation and stable vascular disease\u00a0(ie, >1 year with no acute events)\u00a0and that antiplatelet therapy “should not be prescribed” in those without a subsequent cardiovascular event. The American College of Chest Physicians clinical practice guidelines —\u00a0see\u00a0Chest. 2012 Feb; 141 (2 Suppl):e531S-75S<\/strong>) —\u00a0similarly\u00a0recommends\u00a0that\u00a0for those with atrial\u00a0fib and high CHADS(2) score who do not have an intracoronary stent placed and are on OAC plus\u00a0APT\u00a0therapy for one year, to stop the\u00a0APT.\u200b<\/p>\n So, as per usual, would be great to have a well-designed randomized controlled trial of patients with atrial fibrillation plus coronary artery disease,\u00a0comparing clinical outcomes in those assigned to the combo of OAC and antiplatelet therapy with those on OAC alone. So, what is one to do in the absence of a definitive study? given the increased likelihood of\u00a0very serious consequences of major bleeds on the combo therapy (35% mortality in these events in the current study), it seems reasonable to me that\u00a0\u00a0in those patients who have stable CAD (eg, 1 year after MI or coronary revascularization),\u00a0the safest route is to use OAC alone… and in those with atrial fibrillation and no documented CAD, not even to consider APT in addition to OAC.<\/p>\n Geoff<\/p>\n <\/p>\n","protected":false},"excerpt":{"rendered":" Aspirin plus warfarin for afib and cad??? […]<\/p>\n![\"aspirin\"](\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/files\/2014\/11\/aspirin-300x200.jpg\")
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